Integrating Mental Health in Primary Care Centres in Pakistan

Innovation summary

Pakistan suffers from a large treatment gap with a handful of institutions and professionals providing appropriate treatment. A WHO-AIMS report on the mental health system in Pakistan found that only 0.28 psychologists are available for every 100,000 people in the country¹. Moreover, stigma also limits demand for mental health services. Integrating mental health services within routine primary health care clinics has been recommended as one solution to increase the accessibility of mental health care in low-resource settings^2-3.

This innovation aims to bridge the mental health delivery gap by increasing demand for services and building capacity for a task-shifting approach that utilizes community health workers to deliver mental health services in under-resourced settings. Health workers are trained in lay counselling using a Basic Counselling Skills Training Manual that was developed by IRD. It has been used to train over 180 lay counsellors.

The innovation integrates mental health screening, counselling and referrals (for severe cases) in primary care centres (in Karachi, Pakistan) through a partnership with clinic networks catering to low income populations, with a strong focus on providing care to mothers.

Impact summary

Coverage: Screened approximately 106,792 people for symptoms of common mental health disorders and provide counselling to 3,121 patients in one year
Outcome: Reduction in symptoms of depression and anxiety on Patient Health Questionnaire 9 (PHQ-9) and General Anxiety Disorder 7 (GAD-7)
Cost-effectiveness: The cost of mental health integrated services is less than USD 15 per patient as measured by Time-Driven Activity Based Costing (TDABC)

“Through counselling I came to realise that my problems were not as unmanageable and overpowering as I initially thought. My motivation has increased and I now use my time productively. I’m smiling now, and this makes my friends and family very happy.”

Counselling client, female, 20 years

Innovation details

Research on antenatal depression and anxiety among pregnant women in Pakistan is scarce, despite depressive disorders being a major disease burden, particularly in low and middle income countries. Studies estimate the prevalence of depression amongst pregnant Pakistani women to range between 36% to 40%⁴, while anxiety among pregnant women has been found to be as high as 49%⁵.

There is also a large treatment gap in the country with a handful of institutions and professionals providing appropriate treatment. Rather than using specialised care settings to address mental disorders, integrated primary care settings optimise health worker interventions for mental health through ‘task-sharing’—delegating tasks and responsibilities from more specialised mental health clinicians to less specialised health workers.

In April 2018, Interactive Research and Development Pakistan integrated mental health services in eight primary care sites through the task-sharing approach within Indus Health Network’s Primary Care Program. Through support from Grand Challenges Canada’s Transition to Scale funding, they are working with three partner healthcare organizations to take this innovation to scale. All of these partners have a strong focus on maternal, neonatal, child health and nutrition within their primary care programs.

The primary aim of the program is to improve mental health outcomes of at least 3,121 patients, with 85% of beneficiaries being women. The improved outcome will be measured by comparison of pre and post intervention scores on PHQ-9 and GAD-7. The program also aims to improve the quality of life of people suffering from mental health issues as measured by baseline and endline comparisons on the Manchester Short Assessment of Quality of Life (MANSA) scale.

The innovation components to achieve it’s targets for capacity building, screening and enrolment are as follows:

Training of Lay Counsellors – This is done using a Basic Counselling Skills Training Manual that was developed by IRD, with support from Grand Challenges Canada. It has been used to train over 100 lay counsellors.
Screening for Common Mental Disorders, specifically Depression and Anxiety - All patients over the age of 15years are screened for symptoms of depression and anxiety using PHQ-4 as part of the primary care service cycle. Those symptomatic are further assessed PHQ-9 and GAD-7 by lay counsellors.
First Line Counselling - Based on the assessment, patients are enrolled for 4 – 6 counselling sessions with the lay counsellor at the facility. The option of home and phone counselling is provided for patients unable to continue sessions at the facility.
Referral - The program psychologist is the point of referral for lay counsellors for cases which need further evaluation. These include cases of suicide ideation, self-harm, or other symptoms of severe anxiety/depression. The psychologist evaluates the patient and continues therapy sessions with the patient or refers to a psychiatrist, subject to need.

Challenges

Logistical challenges

Patients tend to leave the facility after meeting the doctor without touching base with the mental health counsellor. This challenge is being addressed by reinforcing the workflow, providing training to facility personnel and obtaining buy-in from the doctors.

Loss to Follow up (FUP)

Some individuals only visit the facility once and do not come back for a counselling session if they did not need to meet the doctor. This increases the lost to FUP rate. To mitigate this, clients are contacted and encouraged to attend counselling sessions. Doctors are also requested to encourage their patients to complete 4-6 counselling sessions. In addition, the option of phone and home-based counselling is also provided

Gendered Access

Access to mental healthcare, much like other well-being outcomes, is highly gendered in Pakistan. This due to women’s inequitable access to resources, time poverty and limitations to mobility. The PSZ primary care integration has been carefully designed keeping the local and cultural context in mind, with features such as free-of-cost mental healthcare services, option of home-based counselling and an equitable mix of female and male counsellors (3:1).

Continuation

We are currently piloting this model in rural populations by integrating mental health services in existing community health worker (CHW) programs, in partnership with a family planning program with a large network of CHWs across Pakistan. One component of this study is to measure willingness to pay through a survey of patients who availed services, in order to explore sustainability options.

Partners

Indus Health Network (IHN), Pakistan
SINA Health, Education and Welfare Trust, Pakistan
Zubaida Machiyara Trust (ZMT), Pakistan
Sehat Kahani, Pakistan
HANDS, Pakistan

Funders

Grand Challenges Canada

Evaluation methods

The innovation evaluated the programme through the following indicators:

Well-being: Improved well-being of patients as measured through pre and post comparison of key indicators. These include:

PHQ-9, GAD-7 to evaluate mental health outcomes
Manchester Short Assessment of Quality of Life (MANSA) to evaluate quality of life

Cost effectiveness: The cost and time effectiveness for the program as measured using Time Driven Activity Based Costing (TDABC)

Patient and Provider Experience: Patient and provider experience will be assessed 6 months after the implementation of the program through a qualitative research study using focus groups and in-depth interviews with patients, counsellors and other key stakeholders of the program

Quality Control and Fidelity:

Standard of Procedures (SOPs) and performance checklists are developed for counselling, data collection and management prior to implementation
Adherence to the SOPs is ensured by weekly spot-checks by the programmatic team and monthly performance evaluations based on the checklist
Data reports are compiled and reviewed twice a week by the program team to track progress

Cost of implementation

A Time-Driven Activity-Based Costing (TDABC) will estimate the operational cost of providing mental health treatment (4-6 counselling sessions per patient).

Impact details

Integrated mental health services through the task-sharing approach within three large scale primary care networks with sites across the provinces Punjab and Sindh.
Screening at least 106,792 individuals (Male = 26,698, Female = 80,094 ) for symptoms of anxiety and/or depression and offered free mental health counseling services to over 10,000 clients.
The programme has registered a community prevalence of anxiety and depressive symptoms within 6% of the population screened
Of these, 2,235 community members have been enrolled for counselling.

References

World Health Organization. Mental Health System in Pakistan. Report, 2009.
Hussain, S. S., Khan, M., Gul, R., & Asad, N. (2018). Integration of mental health into primary healthcare: Perceptions of stakeholders in Pakistan. Eastern Mediterranean Health Journal, 24(2), 146–153. https://doi.org/10.26719/2018.24.2.146
Eaton, J., Gureje, O., De Silva, M., Sheikh, T. L., Ekpe, E. E., Abdulaziz, M., Muhammad, A., Akande, Y., Onukogu, U., Onyuku, T., Abdulmalik, J., Fadahunsi, W., Nwefoh, E., & Cohen, A. (2018). A structured approach to integrating mental health services into primary care: Development of the Mental Health Scale Up Nigeria intervention (mhSUN). International Journal of Mental Health Systems, 12(1), 11. https://doi.org/10.1186/s13033-018-0188-0
Sabir, M., Nagi, M. L. F., & Kazmi, T. H. (2019). Prevalence of antenatal depression among women receiving antenatal care during last trimester of pregnancy in a tertiary care private institute of Lahore. Pakistan Journal of Medical Sciences, 35(2), 527–531. https://doi.org/10.12669/pjms.35.2.649
Waqas, A., Raza, N., Lodhi, H. W., Muhammad, Z., Jamal, M., & Rehman, A. (2015). Psychosocial Factors of Antenatal Anxiety and Depression in Pakistan: Is Social Support a Mediator? PLoS ONE, 10(1). https://doi.org/10.1371/journal.pone.0116510